S Sulaiman, K Wei Chong* M Gaudoin+
South Glasgow University Hospitals NHS Trust, Glasgow, *Medical student, University of Glasgow, +Department of Obstetrics & Gynaecology, Southern General Hospital, Glasgow
Corresponding author Dr Marco Gaudoin, Consultant Obstetrician & Gynaecologist, Dept of Obstetrics & Gynaecology, Southern General Hospital, 1345 Govan Rd, Glasgow G51 4TF. E-mail: Marco.Gaudoin@sgh.scot.nhs.uk
SMJ 2004 49(4): 152-154
Background. Postmenopausal bleeding (PMB) is a common problem and reason for referral to gynaecology clinics. Aims. The aim of this study was to compare patient management and outcomes from a newly developed one-stop clinic for women with PMB with traditional gynaecology outpatient clinics. Methods. Retrospective studying running from January to July 2003 comparing the one-stop clinic with four traditional consultantled outpatient gynaecology clinics also seeing women with PMB running concurrently in the same hospital. Results. In the study period, 95 and 51 women were seen in each type of clinic. There was no difference in patient demographics but the time from referral to first consultation was shorter in the PMB clinic (p<0.001) and women had fewer visits (p<0.001). The mean time from first consultation to definitive treatment or discharge was also shorter (p<0.001). Fewer hysteroscopies were generated from the PMB clinic (p<0.0001) and yet there was no difference in the rates of abnormal histology between the two groups. Conclusions. This study demonstrated that one-stop investigation of PMB, compared to traditional outpatient clinics, reduced waiting times and theatre costs by reducing the number of hysteroscopies.
Key words: One-stop PMB clinic, waiting times, theatre costs, computerisation
Postmenopausal bleeding (PMB) is one of the most common gynaecological referrals from general practice and, as the population ages, will become proportionately more common. In approximately 60% of women no organic cause is found whilst benign causes of PMB may be related to endometrial polyps, submucous fibroids, HRT, atrophic vaginitis and functional endometrium.1 Investigations for PMB include assessment of the endometrium by transvaginal ultrasound scan (TVS) and outpatient endometrial sampling or hysteroscopy and curettage. TVS may be as effective as hysteroscopy for the detection of intrauterine lesions2 but its specificity, compared with hysteroscopy and curettage suggests that additional investigations are required to detect malignant disease.3 Outpatient endometrial sampling provides histological material but its value as a single intervention is limited as it misses polyps, myomas and endometrial cancers in 10–25% of cases.4 In light of this, the Scottish Intercollegiate Guidelines Network (SIGN) has produced guidelines for investigating PMB, focusing on the detection of endometrial cancer.5
Often women with postmenopausal bleeding require multiple visits to hospital to achieve a final management plan. Hence, the aim of this study was to compare waiting times, investigations performed and histological outcomes between traditional gynaecology clinics with a newly developed one-stop PMB clinic.
Women with PMB were referred to a Glasgow city hospital by their general practitioners between January 1, 2003 and July 31, 2003. Women were either referred to the onestop PMB clinic or a traditional general gynaecology clinic. The one-stop Clinic was started on January 6, 2003 and is run by a single consultant with a nursing assistant. For experiential purposes, a trainee may also be present but is supernummary to the clinic. Four different consultants lead the general gynaecology clinics which are staffed by a consultant, registrar and SHO with nursing support. In the PMB Clinic a gynaecological history was obtained and abdominal palpation performed. A TVS and endometrial sampling were carried out at one visit where feasible. Finally, treatment options were discussed based on the results of the scan and quantity of tissue obtained.
Hysteroscopy in theatre was arranged if the TVS was suspicious or if warranted by the subsequent endometrial histology. In accordance with the SIGN guidelines, any woman on tamoxifen did not have outpatient investigations but had a hysteroscopy arranged directly. The patient’s data was entered on to a password-protected Microsoft Access database on a password-protected computer by MG at the end of each clinic. This allowed generation of mail-merge management and discharge letters on the day of consultation. Once any histological results were obtained a final letter was sent to the patient with a copy to her general practitioner. There is no facility for outpatient hysteroscopy in our hospital.
In the general clinics scans, Pipelle sampling and hysteroscopy were arranged according to an individual clinician’s personal preference. Usually women had to be given another date to attend for a scan and only in some women was endometrial sampling performed at their first visit. Others were given dates for ultrasound and hysteroscopy simultaneously i.e. before the result of the transvaginal scan was known. The names and hospital numbers of patients who attended the general clinics in the study period were obtained from the register of postmenopausal patients who had undergone ultrasound and/or hysteroscopy in main or day surgery theatre. Case notes were retrieved from medical records by SS and KWC and relevant data entered in to a proforma and transferred on to a password-protected Microsoft Access database for subsequent analysis. For the purposes of this study, women were considered postmenopausal if their last menstrual bleeding was more than one year previously. Mean values and standard deviations were determined using SPSS statistical programme (Version 8.0, North Carolina) and data was analysed by the authors using Student’s t-test and c2-test as appropriate.
In the study period, 95 women were referred to the onestop clinic and 51 women to the general clinics. There was no difference in age, parity or past history of breast cancer between the two groups. Only one woman (in the PMB group) was currently taking Tamoxifen. Compared to the general clinics, more women in PMB clinic were on some form of HRT (p<0.05).
Table I shows that the time from referral to first consultation was shorter in the PMB clinic (35±17 days, p<0.001) and the women had fewer visits (1.3±0.6 visits, p<0.001). The time to TVS in the general clinic was longer, (20±16 days, p<0.0001) but there was no difference in the total number of scans performed. In the PMB clinic the maximum number of hospital visits was three (initial visit, subsequent formal hysteroscopy and curettage and follow-up appointment, usually to impart a diagnosis of malignancy and plan ongoing management). In the general clinics the maximum number of hospital visits was five.
Only three women in the PMB clinic did not have a transvaginal scan (one because of immobility, another who was virgo intacta and could not tolerate a vaginal probe and another who was on Tamoxifen) and hysteroscopy under general anaesthesia was arranged directly in each case. Overall, for the women who were scanned in the two groups, there was no difference in the mean endometrial thickness. In the PMB clinic, 42 women (44%) were not taking HRT and a further 23 were using a continuous combined HRT preparation. The mean endometrial thickness in these 65 women was 4.4±4.8mm. In the traditional outpatient clinic, 37 women (73%) were not taking HRT and a further 12 were using a continuous combined HRT preparation. Fortyeight of these women had a scan and the mean endometrial thickness was 4.0±3.6mm (p=NS). In the one-stop clinic, 74 women (78%) had an endometrial sample compared to 26 (51%) in the traditional outpatient clinic (p<0.0001). A Pipelle sample could not be obtained from 16 women (17%) in the PMB clinic and of these, 11 had an endometrial thickness greater than 3mm and hysteroscopy under general anaesthesia was arranged. Five women did not have outpatient endometrial sampling attempted (three for the same reasons that they did not have a transvaginal scan and two others who had previously had a hysterectomy).
Fewer hysteroscopies were generated from the PMB clinic (18% cf. 51%; p<0.0001) and yet there was no difference in the mean endometrial thickness or rates of abnormal histology between the two groups. Overall there were 10 women who required hysterectomy. Three women had atypical hyperplasia (one had an endometrial thickness less than 3mm) and none was on HRT. Seven women had overt malignancy - one ovarian and six endometrial cancers. Of the women with endometrial cancer, five were not on HRT and one was on a continuous combined preparation. Five of these women were scanned and in four cases the endometrial thickness was greater than 3mm. However, in the fifth case the endometrial thickness was less than 3mm but malignant cells were detected at hysteroscopy. The sixth patient had a hysteroscopy arranged directly from the PMB clinic and did not have a scan because she was virgo intacta (see above). Two of the three endometrial cancers from the PMB clinic were detected on Pipelle sampling. The three cancers from the traditional clinic were all detected at hysteroscopy.
Overall, the time from first consultation to a definitive management plan with a letter sent to the GP was shorter in the PMB clinic (6±6 days, p<0.001). Sixty-eight women (72%) in the PMB clinic received immediate reassurance and were discharged after the first consultation compared to six per cent from the general clinic (p<0.0001).
In this study there was no difference in clinical outcomes between the two groups with respect to histological diagnoses but the time from GP referral to first appointment was considerably quicker for women attending the one-stop PMB clinic and overall they attended on fewer occasions (p<0.001). More women in the one-stop clinic had an endometrial sample performed (p<0.0001). The PMB clinic generated fewer hysteroscopies and the majority of women were managed at a single visit (p<0.0001).
The time from first consultation to a definitive management plan or discharge letter was shorter in the PMB clinic (p<0.001). This was facilitated by computerisation of all the patient data and the ability to generate mail-merge management and discharge letters. This meant that letters were printed, signed and sent on the day of the clinic with the minimum of secretarial input, unlike traditional clinics where there is inevitably a delay between dictation and letters being sent.
In the vast majority of women when the endometrial thickness is less than 3mm, the risk of endometrial cancer is low.5 However, there was one case each of endometrial atypia and cancer in which the endometrium was thin. These findings, we believe, support our policy of endometrial sampling (which is inexpensive and relatively non-invasive) in all women where possible rather than limiting it to women with thicker endometrium. Retrospective studies are inevitably susceptible to inherent bias. However, we believe that the advantage of this retrospective study was that individual clinicians could not alter their usual management plan for women with PMB which may have been the case if the study had been prospective. Hence, it represented a true reflection of current management.
Although the time from referral to first consultation in the one-stop clinic was shorter than the traditional clinic, it was disappointingly longer than we had hoped. This might be explained by the observation that the clinic is run by a single consultant (MG) on a Monday morning. If he is away then the clinic is cancelled and, furthermore, in the study period the day coincides with a number of local and national public holidays when the clinic is cancelled as well. This was less likely to happen from the four other clinics which continued to run (with a registrar) even if the consultant was away. Importantly, it was also a new and unfamiliar service for local general practitioners so referrals were not maximised. In support of this, in the last five months of 2003, 104 women were seen at the one-stop clinic and the mean time from referral to clinic attendance was just 19 days±8 days (p<0.001), in keeping with other published data.3
This study demonstrated that the one-stop clinic is costeffective. It reduced the number of hysteroscopies performed and, unlike many one-stop breast clinics, does not rely on a pathologist to be available to analyse the tissue samples immediately to provide patient reassurance. The value of demonstrating thin endometrium, especially if no tissue is obtained with the Pipelle sampler, is in itself a very reassuring finding which can be imparted to the patient immediately and ongoing definitive management discussed at that time. Even if tissue is obtained, the thin endometrium makes significant pathology unlikely and a letter can be sent (and management altered if necessary) once the histological specimen has been analysed. Furthermore, computerisation minimised secretarial input and allowed a letter detailing the patient’s findings and ongoing management to be sent on the day of consultation so that general practitioners received correspondence promptly.
To our knowledge this is the first study to compare directly a one-stop clinic with a traditional outpatient clinic running concurrently within the same unit. It demonstrated that the clinic reduced waiting times and saved substantially on theatre costs. Importantly, the majority of women received reassurance and a defined management plan at a single visit. Hence, the one-stop clinic also fulfils the Department of Health’s aim of supporting treatments that are cost effective and yet clinically orientated.6 If implemented on a wider scale, it would mean that women with PMB are seen at a dedicated clinic which, in turn, allows women with other gynaecological problems to be seen at the general clinics. This would inevitably reduce waiting times for all women regardless of their clinical problem and we believe such clinics, which utilise established guidelines and take advantage of readily available computer technologies, should be promoted actively.
ACKNOWLEDGMENTS: Our thanks to Medical Records staff at the Victoria Infirmary, Glasgow, for providing the patients’ case notes.
REFERENCES
1 Karlsson B, Granberg S, Wikland M, Ylostalo P, Torvid K, Marsal K, Valentin L. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding – A Nordic multicenter study. Am J Obstet Gynecol 1995; 172(5):1488-94
2 Omnes S, Chatellier G, Durieux P, Matzger U, Camatte S, Lievre L, Lecuru F. Value of sonography for diagnosis of endometrial carcinoma in patients with postmenopausal bleeding. Int J Gynecol Cancer. 2003; 13(1):26
3 Mohamed H and Nair P. One-stop clinic for postmenopausal bleeding at a district general hospital: does it have a role? J Obstet Gynaecol 2003; 23(2):182-4
4 Dueholm M, Laursen H, Knudsen UB. A simple one-stop menstrual problem clinic with use of hysterosonography for the diagnosis of abnormal uterine bleeding. Acta Obstet Gynecol Scand1999; 78(2): 150-4
5 Investigation of post-menopausal bleeding. SIGN Guidelines No. 61. Scottish Intercollegiate Guidelines Network, 2002. Available from: http:// www.sign.ac.uk
6 The NHS Plan (2002). Improvement, expansion and reform - the next 3 years: priorities and planning framework 2003-2006. Available from: http:// www.doh.gov.uk